Levels & Trends in Child Mortality Report 2011 docx

The global under-five mortality rate needs to be halved from 57 deaths per 1,000 live births to 29—that implies an average rate of reduction of 13.5 percent a year, much higher than the

Levels & Trends in

Child

Mortality

Report 2011

Estimates Developed by the

UN Inter-agency Group for Child Mortality Estimation

United Nations DESA/Population Division

This report was prepared at UNICEF Headquarters by Danzhen You, Gareth Jones and Tessa Wardlaw on behalf of the

United Nations Inter‑agency Group for Child Mortality Estimation

Organizations and individuals involved in generating country-specific estimates on child mortality

United Nations Children’s Fund

Danzhen You, Tessa Wardlaw

World Health Organization

Ties Boerma, Colin Mathers, Mie Inoue, Mikkel Oestergaard

The World Bank

Emi Suzuki

United Nations Population Division

Francois Pelletier, Gerhard Heilig, Kirill Andreev, Patrick Gerland, Danan Gu, Nan Li, Cheryl Sawyer, Thomas Spoorenberg

United Nations Economic Commission for Latin America and the Caribbean Population Division

Dirk Jaspers Faijer, Guiomar Bay, Tim Miller

Special thanks to the Technical Advisory Group of the Inter-agency Group for Child Mortality Estimation for providing technical guidance on methods for child mortality estimation

Kenneth Hill (Chair), Harvard University Michel Guillot, University of Pennsylvania

Leontine Alkema, National University of Singapore Jon Pedersen, Fafo

Simon Cousens, London School of Hygiene and Tropical Medicine Neff Walker, Johns Hopkins University

Trevor Croft, Measure DHS, ICF Macro John Wilmoth, University of California, Berkeley Gareth Jones, Consultant

Further thanks go to Priscilla Akwara, Mickey Chopra, Archana Dwivedi, Jimmy Kolker, Richard Morgan, Holly Newby and Ian Pett from UNICEF for their support as well as to Joy Lawn from Save the Children for her comments And special thanks to Mengjia Liang from UNICEF for her assistance in preparing the report.

Communications Development Incorporated provided overall design direction, editing and layout.

Copyright © 2011

by the United Nations Children’s Fund

The Inter‑agency Group for Child Mortality Estimation (IGME) constitutes representatives of the United Nations Children’s Fund, the World Health Organization, the World Bank and the United Nations Population Division The child mortality esti‑ mates presented in this report have been reviewed by IGME members As new information becomes available, estimates will

be updated by the IGME Differences between the estimates presented in this report and those in forthcoming publications

by IGME members may arise because of differences in reporting periods or in the availability of data during the production process of each publication and other evidence While every effort has been made to maximize the comparability of statistics across countries and over time, users are advised that country data may differ in terms of data collection methods, population coverage and estimation methods used.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNICEF, the World Health Organization, the World Bank or the United Nations Population Division concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its fron‑ tiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement

On 9 July 2011 the Republic of South Sudan seceded from the Republic of the Sudan and was subsequently admitted to the United Nations on 14 July 2011; disaggregated data for Sudan and South Sudan as separate states are not yet available Data and maps in this report refer to Sudan as it was constituted in 2010.

PROGRESS TOWARDS MillEnniuM DEvElOPMEnT GOAl 4:

KEY FACTS AnD FiGuRES

2000 to 2000–2010 Six of the fourteen best-performing countries are in Sub-Sa-haran Africa, as are four of the five coun-tries with the largest absolute reductions (more than 100 deaths per 1,000 live births)

• About half of under-five deaths occur in only five countries: India, Nigeria, Dem-ocratic Republic of the Congo, Pakistan and China India (22 percent) and Nigeria (11 percent) together account for a third

of all under-five deaths

• Over 70 percent of under-five deaths occur within the first year of life

• The proportion of under-five deaths that occur within the first month of life (the neonatal period) has increased about

10 percent since 1990 to more than 40 percent

• Almost 30 percent of neonatal deaths occur in India Sub-Saharan Africa has the highest risk of death in the first month of life and has shown the least progress

• dren under age 5 are pneumonia (18 percent), diarrhoeal diseases (15 per-cent), preterm birth complications (12 percent) and birth asphyxia (9 percent)

Globally, the four major killers of chil-Undernutrition is an underlying cause in more than a third of under-five deaths

ran Africa, causing about 16 percent of under-five deaths

Only four years remain to achieve Millennium

Development Goal 4 (MDG 4), which calls for

reducing the under-five mortality rate by

two-thirds between 1990 and 2015 Since 1990 the

under-five mortality rate has dropped 35 percent,

with every developing region seeing at least a 30

percent reduction However, at the global level

progress is behind schedule, and the target is at

risk of being missed by 2015 The global

under-five mortality rate needs to be halved from 57

deaths per 1,000 live births to 29—that implies

an average rate of reduction of 13.5 percent a

year, much higher than the 2.2 percent a year

achieved between 1990 and 2010

Child mortality is a key indicator not only of child health and nutrition but also of the implemen-tation of child survival interventions and, more broadly, of social and economic development As global momentum and investment for accelerat-ing child survival grow, monitoring progress at the global and country levels has become even more critical The United Nations Inter-agency Group for Child Mortality Estimation (IGME) updates child mortality estimates annually for monitoring progress This report presents the IGME’s latest estimates of under-five, infant and neonatal mortality and assesses progress towards MDG 4 at the country, regional and global levels

The UN Inter-agency Group for

Child Mortality Estimation

The IGME was formed in 2004 to share data on

child mortality, harmonize estimates within the

UN system, improve methods for child

mortal-ity estimation, report on progress towards the

Millennium Development Goals and enhance

country capacity to produce timely and

prop-erly assessed estimates of child mortality The

IGME, led by the United Nations Children’s

Fund (UNICEF) and the World Health

Organiza-tion (WHO), also includes the World Bank and

the United Nations Population Division of the

Department of Economic and Social Affairs as

full members

The IGME’s independent Technical Advisory

Group, comprising leading academic scholars

and independent experts in demography and

biostatistics, provides guidance on estimation

methods, technical issues and strategies for data

analysis and data quality assessment

Generating accurate estimates of child

mortal-ity poses a considerable challenge because of the

limited availability of high-quality data for many

developing countries Complete vital

registra-tion systems are the preferred source of data on

child mortality because they collect information

as events occur and they cover the entire

popula-tion However, many developing countries lack

fully functioning vital registration systems that

accurately record all births and deaths

There-fore, household surveys, such as the

UNICEF-supported Multiple Indicator Cluster Surveys and

the US Agency for International Development–

supported Demographic and Health Surveys, are

the primary sources of data on child mortality in

developing countries

The IGME seeks to compile all available

national-level data on child mortality, including data from

vital registration systems, population censuses,

household surveys and sample registration

sys-tems To estimate the under-five mortality trend

series for each country, a statistical model is fitted

to data points that meet quality standards

estab-lished by the IGME and then used to predict a

trend line that is extrapolated to a common

ref-erence year, set at 2010 for the estimates in this

report To predict infant mortality rates, model

life tables are used to transform under-five

mor-tality rates To predict neonatal mormor-tality rates, a

statistical model is used to transform under-five mortality rates

Changes to data sources and methodology

The IGME updates its child mortality estimates annually after reviewing newly available data and assessing data quality In preparing the estimates in this report, the IGME recalculated direct estimates from all available Demographic and Health Surveys for calendar year periods, using single calendar years for reference peri-ods shortly before the survey and then gradu-ally increasing the number of years for reference periods further in the past For a given survey the cut-off points for shifting from estimates for single calendar years to two years, or two years

to three and so on are based on the coefficients

of variation (a measure of sampling uncertainty)

of the estimates The Technical Advisory Group suggested this recalculation because the sam-ple sizes of many household surveys have grown

in recent years, allowing for shorter reference periods The recalculated direct estimates with shorter reference periods replace the five-year periods used in previous estimations, thereby increasing the number of data points for more recent years

In addition, a substantial amount of newly able data has been incorporated: data from the most recent surveys and censuses for about

avail-30 countries, new data from vital registration systems for more than 50 countries and data from more than 70 surveys and censuses con-ducted before 2000 for about 20 countries The increased data availability has resulted in sub-stantial changes in the estimates for some coun-tries from previous years Because the fitted under-five mortality rate trend line is based on the entire time series of data available for each country and because model life tables and a sta-tistical model are used to derive estimates of infant and neonatal mortality rates based on under-five mortality rates, the estimates pre-sented in this report may differ from and not be comparable with previous sets of IGME estimates and the most recent underlying country data

Furthermore, this year the IGME used a different curve-fitting methodology More details on the data and methods used in deriving the estimates are available in the IGME’s child mortality data-base, CME Info (www childmortality.org)

Support for data collection

at country level

Modelled estimates of child mortality can only be

as good as the underlying data The IGME

mem-bers, including UNICEF, the WHO and other

UN agencies, are actively involved at the country

level in strengthening national capacity in data

collection, estimation techniques and

interpreta-tion of results

Population-based survey data are critical for

developing sound estimates for countries

lack-ing functionlack-ing vital registration systems The

UNICEF-supported Multiple Indicator Cluster

Surveys programme has been working since 1995

to build country-level capacity for survey

imple-mentation, data analysis and dissemination The

surveys are government owned and implemented,

and UNICEF provides financial and technical

support through workshops, technical

consulta-tions and peer-to-peer mentoring More than

230 surveys have been conducted in more than

100 countries In addition to population-based

surveys, the WHO and the UN Statistics

Divi-sion work with countries to strengthen vital

reg-istration systems UNICEF supports this work by

promoting birth registration and monitoring its

progress The United Nations Population Fund

provides technical assistance for population

cen-suses, another important source of child

mortal-ity data

The IGME strengthens capacity by working with

countries to improve understanding of child

mortality data and estimation CME Info (www.childmortality.org ), a comprehensive data por-tal on child mortality funded by UNICEF and launched by the IGME, is a powerful platform for sharing underlying data and collaborating with national partners on child mortality estimates Since 2008 a series of regional workshops has been held, training more than 250 participants from

94 countries in the use of CME Info as well as the demographic techniques and modelling methods underlying the estimates In the last three years UNICEF and the IGME have sent experts to about

10 countries to conduct training on child tality estimation As part of the data review pro-cess, UNICEF’s network of field offices provides opportunities to assess the plausibility of estimates

mor-by engaging in a dialogue about the estimates and the underlying data WHO also engages its Member States in a country consultation process through which governments provide feedback on the estimates and their underlying data

Guiding this capacity strengthening work is a fundamental principle: child mortality estima-tion is not simply an academic exercise but a fundamental part of effective policies and pro-gramming UNICEF works with countries to ensure that child mortality estimates are used effectively at the country level, in conjunction with other data on child health, to improve child survival programmes and stimulate action through advocacy This work involves partnering with other agencies, organizations, and initiatives such as the Countdown to 2015

Levels and Trends in

Child Mortality, 1990–2010

Under-five mortality

The latest estimates of under-five mortality from

the UN Inter-agency Group for Child Mortality

estimation (IGME) show a 35 percent decline in

the under-five mortality rate globally, from 88

deaths per 1,000 live births in 1990 to 57 in 2010

(table 1 and figure 1) Over the same period, the

total number of under-five deaths in the world

has declined from more than 12 million in 1990

to 7.6 million in 2010 (table 2)

Five of nine developing regions show reductions

in under-five mortality of more than 50

per-cent over 1990–2010 (figure 2) Northern Africa

has achieved MDG 4, with a 67 percent

reduc-tion, and Eastern Asia is close, with a 63 percent

reduction

Sub-Saharan Africa and Oceania have achieved

only around a 30 percent reduction in under-five

mortality, less than half that required to reach

MDG 4 However, Sub-Saharan Africa—also

com-bating the HIV/AIDS pandemic that has affected

countries in the region more than elsewhere in

the world—has doubled its average rate of

reduc-tion from 1.2 percent a year over 1990–2000 to

2.4 percent a year over 2000–2010

A major reason for the limited progress in

reduc-ing child mortality at the global level, despite

more than half the regions having already

achieved reductions of more than 50 percent, is

the large and growing share of under-five deaths

that occur in Sub-Saharan Africa and Southern

Asia (82 percent; figures 3 and 4) Of the 26

coun-tries with under-five mortality rates above 100

deaths per 1,000 live births in 2010, 24 are in

Sub-Saharan Africa (map 1) Thus, to achieve MDG 4,

substantial progress is needed in both regions

Fourteen of sixty-six countries with at least 40

under-five deaths per 1,000 live births in 2010

reduced their under-five mortality rate by at least

half between 1990 and 2010 (figure 5)

Timor-Leste, Bangladesh, Nepal, the Lao People’s

Democratic Republic, Madagascar and Bhutan recorded declines of at least 60 percent, or more than 4.5 percent a year on average In absolute terms the greatest reductions were in Niger, Malawi, Liberia, Timor-Leste and Sierra Leone (surpassing 100 deaths per 1,000 live births dur-ing the period) That 9 of the 14 countries are from Sub-Saharan Africa and Southern Asia, the two regions most in need of a faster reduction of the under-five mortality rate, shows that substan-tial progress can be made in these regions

Among developed regions under-five mortality rates exceeded 10 deaths per 1,000 live births in

2010 in the Republic of Moldova, Albania, nia, Ukraine, Bulgaria, Russian Federation and The former Yugoslav Republic of Macedonia

Roma-Some 70 percent of the world’s under-five deaths

in 2010 occurred in only 15 countries, and about half in only five countries: India, Nigeria, Demo-cratic Republic of the Congo, Pakistan and China (figure 6) India (22 percent) and Nigeria (11 percent) together account for a third of under-five deaths worldwide

Overall, substantial progress has been made towards achieving MDG 4 About 12,000 fewer children died every day in 2010 than in 1990, the baseline year for measuring progress Improve-ment in child survival is evident in all regions

The number of countries with under-five tality rates of 100 deaths per 1,000 live births or higher has been halved from 52 in 1990 to 26 in

mor-2010 In addition, no country had an under-five mortality rate above 200 deaths per 1,000 live births in 2010, compared with 13 countries in

1990 The rate of decline has accelerated from 1.9 percent a year over 1990–2000 to 2.5 percent

a year over 2000–2010 Moreover, in Sub-Saharan Africa, the region with the greatest burden of under-five deaths, the rate of decline doubled

But these rates are still insufficient to achieve MDG 4 by 2015: only 6 of 10 regions are on track

to achieve the MDG 4

2 levels and trends in the number of deaths of children under age five, by Millennium

Development Goal region, 1990–2010 (thousands)

Decline (percent)

1990–2010

Share of global under-five deaths (percent)

Latin America and the Caribbean 623 511 397 305 237 249 60 3.3

Caucasus and Central Asia 155 119 86 80 79 78 50 1.0

1 levels and trends in the under-five mortality rate, by Millennium Development Goal region,

1990–2010 (deaths per 1,000 live births)

MDG target 2015

Decline (percent)

1990–2010

Average annual rate

of reduction (percent)

1990–2010

Progress towards Millennium Development Goal 4 target

2010

Developed regions 15 11 10 8 7 7 5 53 3.8 On track

Developing regions 97 90 80 71 64 63 32 35 2.2 Insufficient progress

Northern Africa 82 62 47 35 28 27 27 67 5.6 On track

Sub-Saharan Africa 174 168 154 138 124 121 58 30 1.8 Insufficient progress

Latin America and the Caribbean 54 44 35 27 22 23 18 57 4.3 On track

Caucasus and Central Asia 77 71 62 53 47 45 26 42 2.7 Insufficient progress

Eastern Asia 48 42 33 25 19 18 16 63 4.9 On track

Southern Asia 117 102 87 75 67 66 39 44 2.9 Insufficient progress Excluding India 123 107 91 80 73 72 41 41 2.7 Insufficient progress

South-eastern Asia 71 58 48 39 34 32 24 55 4.0 On track

Western Asia 67 57 45 38 33 32 22 52 3.7 On track

Oceania 75 68 63 57 53 52 25 31 1.8 Insufficient progress

World 88 82 73 65 58 57 29 35 2.2 Insufficient progress

a “On track” indicates that under-five mortality is less than 40 deaths per 1,000 live births in 2010 or that the average annual rate of reduction is at least 4 percent over 1990–2010; “insufficient progress” indicates that under-five mortality is at least 40 deaths per 1,000 live births in 2010 and that the average annual rate of reduction is at least 1 percent but less than 4 percent over 1990–2010 These standards may differ from those in other publications by Inter-agency Group for Child Mortality Estimation members.

FiGuRE

2 Many regions have reduced the under-five mortality rate by at least

50 percent between 1990 and 2010

0 25 50

Latin America and the

Caribbean 249

Southern Asia 2,526

Number of under-five deaths, by Millennium Development Goal region,

2010 (thousands)

FiGuRE

4 The global burden of under-five deaths is increasingly concentrated in Sub-Saharan Africa

0 20 40 60 80 100

Sub-Saharan Africa

Eastern Asia South-eastern Asia

Western Asia

Developed regions Oceania Caucasus and Central Asia

Under-five mortality rate, by Millennium Development Goal region,

1990 and 2010 (deaths per 1,000 live births)

MAP

1 Children in Southern Asia and Sub-Saharan Africa face a higher risk of dying before their fifth birthday

Less than 40

Under-five mortality rate (deaths per 1,000 live births)

Note: Data for Sudan refer to the country as it was constituted in 2010, before South Sudan seceded on 9 July 2011.

6 Half of under-five deaths occur in just five countries

Number of under-five deaths, by country, 2010 (thousands)

India 1,696

Nigeria 861

Dem Rep of

the Congo 465 Pakistan 423

China 315

Uganda 141

Sudan a 143

Other countries 2,958

FiGuRE

5 Of the 66 countries with high under-five mortality, 14 have seen reductions of at

least 50 percent between 1990 and 2010

Decline in under-five mortality rate, 1990–2010 (percent)

As under-five mortality rates have fallen more

sharply in richer developing regions, the

dispar-ity between Sub-Saharan Africa and other regions

has grown In 1990 a child born in Sub-Saharan

Africa faced a probability of dying before age 5

that was 1.5 times higher than in Southern Asia,

3.2 times higher than in Latin America and the

Caribbean, 3.6 times higher than in Eastern Asia

and 11.6 times higher than in developed regions

By 2010 that probability was 1.8 times higher than

in Southern Asia, 5.3 times higher than in Latin

America and the Caribbean, 6.7 times higher

than in Eastern Asia and 17.3 times higher than

in developed regions The disparity between

Southern Asia and richer regions has also grown,

though not as much

Of the 66 countries with at least 40 deaths per

1,000 live births in 2010, only 11 are on track to

achieve MDG 4 (map 2) But substantial advances

have been made, particularly in Sub-Saharan

Africa Six of the fourteen best- performing

coun-tries are in Sub-Saharan Africa (see figure 5),

as are four of the five countries with the largest

absolute reductions in under-five mortality

Thus, there is increasing evidence that MDG 4 can

be achieved, but only if countries in Sub-Saharan

Africa and Southern Asia give high priority to reducing child mortality, particularly by targeting the major killers of children (including pneumo-nia, diarrhoea, malaria and undernutrition) with effective preventative and curative interventions

Neonatal mortality

Neonatal mortality, covering deaths in the first month after birth, is of interest because the health interventions needed to address the major causes of neonatal deaths generally differ from those needed to address other under-five deaths

Neonatal mortality is increasingly important because the proportion of under-five deaths that occur during the neonatal period is increasing as under-five mortality declines

Over the last two decades almost all regions have seen slower declines in neonatal mortality than

in under-five mortality Globally, neonatal tality has declined 28 percent from 32 deaths per 1,000 live births in 1990 to 23 in 2010—an aver-age of 1.7 percent a year, much slower than for under-five mortality (2.2 percent per year) and for maternal mortality (2.3 percent per year)

mor-The fastest reduction was in Northern Africa (55 percent), followed by Eastern Asia and Latin America and the Caribbean (52 percent); the

MAP

2 Many countries were on track in 2010 to achieve Millennium Development Goal 4, but progress needs to accelerate in several regions, particularly in Southern Asia and Sub-Saharan Africa

On track: under-five mortality is less than 40 deaths per 1,000 live

births in 2010 or the average annual rate of reduction of under-five mortality

is at least 4 percent over 1990–2010.

No progress: under-five mortality is at least 40 deaths per 1,000 live births in 2010 and the average annual rate of reduction is less than 1 percent over 1990–2010.

Data not available.

Note: These standards may differ from those in other publications by Inter-agency Group for Child Mortality Estimation members Data for Sudan

refer to the country as it was constituted in 2010, before South Sudan seceded on 9 July 2011.

Insufficient progress: under-five mortality is at least 40 deaths per

1,000 live births in 2010 and the average annual rate of reduction is at least

1 percent but less than 4 percent over 1990–2010.

1,000 live births in 2010) and has shown the least progress in reducing that rate over the last two decades

With the proportion of under-five deaths during the neonatal period increasing in every region and almost all countries, systematic action is required by governments and partners to reach women and babies with effective care Highly cost-effective interventions are feasible even at the community level, and most can be linked with preventive and curative interventions for mothers and for babies For example, early post-natal home visits are effective in promoting healthy behaviours such as breastfeeding and clean cord care as well as in reaching new moth-ers Case management of neonatal infections can be provided alongside treatment of child-hood pneumonia, diarrhoea and malaria Care

at birth brings a triple return on investment, preventing stillbirths and saving mothers and newborns

Disparity in child mortality

Despite substantial progress in reducing five deaths, children from rural and poorer households remain disproportionately affected Analyses based on data from household surveys for a subset of countries indicate that children

under-in rural areas are about 1.7 times as likely to die

slowest reduction was in Oceania and ran Africa (19 percent; table 3)

Sub-Saha-Over the same period the share of neonatal deaths among under-five deaths has increased from about 37 percent to slightly above 40 percent worldwide and is expected to further increase as under-five mortality declines While the relative increase is modest (9 percent) at the global level, there are differences across regions The largest increases have been in Northern Africa (37 percent) and Eastern Asia (27 percent), the smallest in Oceania (7 per-cent; see table 3) In Eastern Asia, which had one of the largest declines in under-five mortal-ity, neonatal deaths accounted for 57 percent of under-five deaths in 2010 Eastern Asia, North-ern Africa and other richer developing regions will have to pay more attention to health inter-ventions that address neonatal mortality in order to continue their success in reducing under-five mortality

Southern Asia also needs to address neonatal mortality: neonatal deaths account for 50 per-cent of under-five deaths, and almost 30 percent

of global neonatal deaths occurred in India

Sub-Saharan Africa, which accounts for more than a third of global neonatal deaths, has the highest neonatal mortality rate (35 deaths per

TAblE

3 neonatal mortality rate, number of neonatal deaths and neonatal deaths as a share of

under-five deaths, by Millennium Development Goal region, 1990 and 2010

Neonatal mortality rate (deaths per 1,000 live births) Number of neonatal deaths (thousands) Neonatal deaths as a share of under-five deaths (percent)

Decline (percent)

Relative increase (percent)

Latin America and the Caribbean 23 11 52 265 117 42 47 11